The Warren Alpert Medical School (formerly known as Brown Medical School, previously known as Brown University School of Medicine) is the medical school of Brown University, located in Providence, Rhode Island, United States. Established in 1811, the school was among the first in the nation to offer academic medical education. Today, Alpert Medical School is a component of Brown’s Division of Biology and Medicine, which also includes the Program in Biology. (A third component of the Division, the Program in Public Health, became the Brown University School of Public Health on July 1, 2013.) Together with the Medical School’s seven affiliated teaching hospitals, the Division attracts over $300 million in external research funding per year.The fourth most selective medical school in the United States, Alpert Medical School earned rankings of twenty-first for primary care education and thirty-first for research in the 2017 U.S. News & World Report rankings. Alpert was also ranked in the top 20 medical schools in the nation by Business Insider. Graduates of Alpert Medical School are accepted into competitive residency programs and leading medical centers.
Importance Nearly all psychopathology is inherently continuous, but both clinical practice and research often require categorical decisions (eg, treat or wait, pay for treatment or decline, enroll in study or not); therefore, thresholds are applied to continuous phenomena to guide these decisions. The most common strategy is to select cutoffs by focusing on diagnoses, but this may be unhelpful in many decisions (eg, selective prevention, choice between treatment options). This review evaluates strategies for developing thresholds for psychopathology dimensions that may enhance clinical decision-making, drawing on methods used in psychiatry, psychology, internal medicine, and health economics. Observations One strategy used extensively in neuropsychology, child psychiatry, clinical psychology, and laboratory medicine is to define multiple thresholds (eg, mild, moderate, and severe), using statistical deviance vis-à-vis the general population. A second strategy is to select thresholds in reference to functional impairment, as has been done for some psychopathology measures. A third approach, common in internal medicine but underused in psychiatry, references probability of a negative outcome (eg, mortality). A fourth option, gaining momentum in European psychiatry, is to select thresholds based on costs and benefits of a clinical action at different levels of severity or risk. Common examples of these 4 strategies are reviewed, comparing their strengths and limitations. They are relevant not only to clinical measures but also research instruments. Value judgments are inherent in approaches 2, 3, and 4; thus, selection of such thresholds requires stakeholder input. Importantly, clinicians make decisions by considering all information, and thresholds are only 1 factor. Conclusions and Relevance Although diagnosis-focused thresholds are sometimes valuable, the field would be served best by also considering the aforementioned alternative strategies. These approaches have been greatly underused in psychiatry, and studies are urgently needed to address this gap. Herein, recommendations are offered for this research.
ObjectiveBuprenorphine is an atypical opioid with analgesic efficacy and a more favorable safety profile than conventional opioids or tramadol. In 2019, access to on-label buprenorphine formulations was limited in comparison to conventional opioids, despite evidence supporting buprenorphine’s first-line analgesic use. Considering recent policy changes increasing buprenorphine accessibility, we determined differences in unrestricted insurance coverage between buprenorphine, conventional opioids, and other atypical opioids.MethodsWe used data from Managed Market Insights and Technology’s Coverage Search and Kaiser Family Foundation to generate estimates on percentages of US-covered lives with unrestricted access to oxycodone, morphine, tramadol, tapentadol, generic and on-label transdermal buprenorphine, on-label buccal buprenorphine, and on-label sublingual buprenorphine/naloxone in 2024.Results79.7% of commercial and 99.1% of Medicare lives had unrestricted oxycodone access. Morphine access was unrestricted for 45.7% of commercial and 62.8% of Medicare lives. Unrestricted access to tramadol was available for 88.2% of commercial and 96.3% of Medicare lives. 37.3% of commercial and 10.1% of Medicare lives had unrestricted tapentadol access. Unrestricted access to on-label transdermal buprenorphine was available for 21.0% of commercial and 2.59% of Medicare lives. Generic transdermal buprenorphine was available for 52.1% of commercial and 30.0% of Medicare lives. Buccal buprenorphine was available without restriction for 52.7% of commercial and 19.8% of Medicare lives. Sublingual buprenorphine/naloxone had unrestricted coverage for 34.6% of commercial and 32.7% of Medicare lives.ConclusionsAccess to buprenorphine formulations was limited in comparison to other opioids. This study emphasizes a need for commercial and Medicare health insurance plans to broaden buprenorphine coverage.
Cervical artery dissection (CAD) is a leading cause of stroke in young adults, accounting for up to 25% of strokes in this population. Despite its prevalence, management strategies vary widely due to limited large-scale randomized trials and inconsistent findings in the literature. This study aims to assess treatment practices for CAD and evaluate the consistency of clinical decision-making among stroke physicians using a structured survey. An international survey was distributed to stroke physicians and trainees, including participants in the STOP-CAD and TREAT-CAD studies. The survey explored patient characteristics influencing treatment decisions, preferred antithrombotics, treatment duration, and criteria for stopping therapy. Six case-based scenarios assessed initial treatment choices, follow-up imaging practices, and medication duration. Responses were analyzed using Krippendorff's alpha to quantify inter-rater reliability and evaluate consensus among respondents. The survey was completed by 102 stroke physicians and trainees, revealing moderate agreement, with a Krippendorff's alpha of 0.481. Significant variability was observed in CAD management, particularly in the choice of antithrombotic treatment and treatment duration. However, strong consensus was found regarding the use of follow-up imaging (99.16%), with computed tomography angiography (CTA) being the preferred modality (63.2%). The variability in CAD management highlights the need for further research to establish standardized, evidence-based guidelines.
